Please provide details below.

1.  Lessee / Tenant Details

Lessee’s Name
Mailing Address
ACN/ABN Number
Contact Officer
Phone
Fax
Email

2.  Lease Details

Real Property Description / Lot on Plan
Street Address of Property
Part or whole of the Lot leased
(Select one.) / Part Whole
Co-located with a School/TAFE
(Select one.) / Yes No
Name of School/TAFE
Lessee’s Service Type
(Select one.) / Kindergarten Long day care centre
Limited hours care Early Years Centre
Children and Family Centre Child and Family Support Hubs

3.  Secondary Provider’s Details and Complementary Services Provided

Please add more complementary services if needed.

3.1  Complementary Service 1

(i)  Secondary Provider’s Details

Date of Consent Granted
Secondary Provider’s Name
Mailing Address
ACN/ABN Number
Contact Officer
Phone
Fax
Email

(ii)  Current Complementary Service Arrangement

Current Delivery Day
(Select all appropriate.) / Monday Tuesday Wednesday Thursday
Friday Saturday Sunday
Current Delivery Time/Term
Current Complementary Service Type
(Select all appropriate.) / Playgroup
Early learning programs
Transition to school programs
Outside school hours care / vacation care
Adjunct care
Child health services
Maternal health services (including maternity services)
Health promotion activities
Parent/family information, support services
Child support services
Other services. Please specify.

(iii)  Variation to Complementary Service Arrangement

For variation only

New Delivery Day
(Select all appropriate.) / Monday Tuesday Wednesday Thursday
Friday Saturday Sunday
New Delivery Time/Term
New Complementary Service Type
(Select all appropriate.) / Playgroup
Early learning programs
Transition to school programs
Outside school hours care / vacation care
Adjunct care
Child health services
Maternal health services (including maternity services)
Health promotion activities
Parent/family information, support services
Child support services
Other services. Please specify.
Other
Please comment

Checklist (please ensure you have):

Attached a copy of documentation regarding the agreement between you and the secondary provider(s) to change the arrangements for complementary services delivered at the ECEC facility.

I declare that all information provided in this application is true and correct.

Signed by:
______
(Lessee delegate’s signature)
Name: ______
Position: ______
Date: ______/ Witnessed by:
______
(Witness’ signature)
Name: ______
Position: ______
Date: ______

For Early Childhood and Community Engagement Division’s Use Only

Date application received: ______TRIM ref: ______

Application processed by: / ______
(Full name)
Position: ______
Date: ______
Once you have completed all sections please submit the completed application form to:
Early Childhood Education and Care
Department of Education and Training
PO Box 15033
CITY EAST QLD 4002
OR

Should you require further information or have an enquiry, please contact
Kindy Hotline 1800 4 KINDY (54639)

Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register

at http://ppr.det.qld.gov.au to ensure you have the most current version of this document. Page 3 of 3